national park service€¦ · web viewnational park serviceexpiration date: 11/15 /2019 nps form...

NPS Form 10-550 (Rev. 11/2016) OMB Control No. 1024-0268National Park Service INSTRUCTIONS Expiration Date: 11/15/2019

COMMERCIAL USE AUTHORIZATION APPLICATION Pu‘uhonua o Hōnaunau NHP and/or Kaloko-Honokōhau NHP

73-4786 Kanalani St #14 Kailua-Kona, HI 96740

CUA CoordinatorPhone Number: (808) 329-6881 ext. 1330

The following explanations correspond directly with the numbered items on the Application Form. Please read this entire document prior to completing the application. Include the nonrefundable application fee when submitting this application.

1. Enter the service you are proposing to provide. These are the services which are currently approved in the park:

Guided hiking/ guided photography/ birdwatching

Wedding ceremonies/wedding photography/ portrait photography

Surf lessons

Bus tours or taxi services

Bicycle tours

See Attachment A

2. Respond “No” or list other parks where you will be providing this service.

3. Enter the legal name of your business. If you have a secondary name under which you are doing business (d.b.a.), please enter that name also.

4. Give the name(s) of persons designated as Authorized Agents for your business. This may include the on-site general manager responsible for day to day operations.

5. Provide contact information for both the main season and the off-season. Over the term of your authorization, it may be necessary to contact you to obtain or share information. Your contact information may also be published in the NPS Commercial Services Directory.

6. Check the box that identifies your type of business.

7. If the state in which you operate or the state where your business is domiciled requires a state business license, provide the license number and year of expiration.

8. Provide your Employer Identification Number (EIN). The Debt Collection Improvement Act of 1996 requires us to collect an EIN or Social Security Number (SSN). The NPS will not collect SSNs, only EINs. The EIN is issued by the Internal Revenue Service. You may receive a free EIN at http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/How-to-Apply-for-an-EIN. We will use the EIN that you provide as needed to collect debts.

9. Provide proof of General Liability Insurance naming the United States of America, as additional insured in the amounts designated in the application. Provide proof of vehicle/vessel/aircraft liability insurance, if required by law, or if visitors are transported by vehicle/vessel/aircraft within the park, or if vehicle/vessel/aircraft are engaged in providing the service (i.e., hauling horses used in the activity). Insurance companies must be rated at least A- by the most recent edition of A.M. Best’s Key Insurance Reports (Property-Casualty edition) or similar insurance rating companies (Moody’s, Standard and Poor’s, or Fitch). Refer to “Attachment B”.

10. Provide a description of and registration number of each vehicle/vessel/aircraft you will utilize during the course of the proposed commercial service.

11. Provide copies of all licenses, vehicle/vessel registration, and certificates of training as required by “Attachment A”.

12. NPS Management Policy prohibits employees of the NPS and their spouses and minor children from acquiring or retaining any authorization for conducting commercial services in a park area.

13. If your business or business owners or current employees or proposed employees have been convicted or are currently under charges for violation of State, Federal, or local law or regulation in the last 5 years, please give details (does not include minor traffic tickets).

14. Include payment of the Application/Administrative Fee: Please submit your application fee of $200 for one park or $300 for both with this application.

15. Please sign and date your application. If the person SIGNING this application is an Authorized Agent for the business, proof of signing authority must accompany this application.

Attachment A: List of Approved Services and Required DocumentationAttachment B: Insurance Requirements

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Commercial Visitor Services, Page i of iii(Item 5D) (N1-79-08-4))

http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/How-to-Apply-for-an-EIN

NPS Form 10-550 (Rev. 11/2016) OMB Control No. 1024-0268National Park Service Expiration Date: 11/15 /2019

Additional Information: The National Park Service has terms and conditions on all commercial service agreements. The following terms and conditions will apply to all Commercial Use Authorizations. There may be additional terms and conditions based on the services provided. These may include but are not limited to limits on locations, times, group size, and employee licenses and certifications and providing such information to the park superintendent for approval.

CONDITIONS OF THIS AUTHORIZATION

1. False Information: The holder is prohibited from knowingly giving false information. To do so will be considered a breach of conditions and be grounds for revocation: [RE: 36 CFR 2.32(a) (3)].

2. Legal Compliance: The holder shall exercise this privilege subject to the supervision of the park area Superintendent. The holder shall comply with all applicable laws and regulations of the area and terms and conditions of the authorization. The holder must acquire all permits or licenses of State or local government, as applicable, necessary to provide the services described above, and, must operate in compliance with all applicable Federal, State, and local laws and regulations, including, without limitation, all applicable park area policies, procedures and regulations. The commercial services described above are to be provided to park area visitors at reasonable rates and under operating conditions satisfactory to the park area superintendent.

3. Rates: The holder shall provide commercial services under this authorization to visitors at reasonable rates and under operating conditions satisfactory to the area Superintendent.

4. Liabilities and Claims: This authorization is issued upon the express condition that the United States, its agents and employees shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, injuries, or death to any person or persons or property of any kind whatsoever, whether to the person or property of the (holder), its agents or employees, or third parties, from any cause or causes whatsoever while in or upon said premises or any part thereof during the term of this authorization or occasioned by any occupancy or use of said premises or any activity carried on by the (holder) in connection herewith, and the (holder) hereby covenants and agrees to indemnify, defend, save and hold harmless the United States, its agents, and employees from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits or losses however occurring or damages growing out of the same.

5. Insurance: Holder agrees to carry general liability insurance against claims occasioned by the action or omissions of the holder, its agents and employees in carrying out activities and operations under this authorization. The policy shall name the United States of America as additional insured. Holder agrees to have on file with the park copies of the above insurance with the proper endorsements.

6. Fees: The Holder shall reimburse the park for all costs incurred by the park as a result of accepting and processing the application and managing and monitoring the authorization activity. Administrative costs for the application process must be paid when the application is submitted. Monitoring fees and any additional costs incurred by the park to support the commercial activity will be paid annually at the end of the year.

7. Benefit: No member of, or delegate to, Congress, or Resident Commissioner shall be admitted to any share or part of this Contract or to any benefit that may arise from this Contract. This restriction shall not be construed to extend to this Contract if made with a corporation or company for its general benefit.

8. Transfer: This authorization may not be transferred or assigned without the written consent of the park area Superintendent.

9. Termination: This authorization may be terminated upon breach of any of the conditions herein or at the discretion of the park area Superintendent.

10. Preference or Exclusivity: The holder is not entitled to any preference to renewal of this authorization except to the extent otherwise expressly provided by law. This authorization is not exclusive and is not a concession contract.

11. Construction: The holder shall not construct any structures, fixtures or improvements in the park area. The holder shall not engage in any groundbreaking activities without the express, written approval of the park area Superintendent.

12. Reporting: The holder is to provide the park area Superintendent upon request (and, in any event, immediately after expiration of this authorization) a statement of its gross receipts from its activities under this authorization and any other specific information related to the holder’s operations that the park area superintendent may request, including but not limited to, visitor use statistics, and resource impact assessments.

13. Accounting: The holder is to maintain an accounting system under which its accounts can be readily identified within its system of accounts classification. This accounting system must be capable of providing the information required by this authorization. The holder grants the United States of America and the Government Accountability Office access to its books and records at any time for the purpose of determining compliance with the terms and conditions of this authorization.

14. Minimum Wage: The holder is required to adhere to Executive Order 13658 – Establishing a Minimum Wage for Contractors, as applicable. The implementing regulations, including the applicable contract clause, are incorporated by reference into this contract as if fully set forth in this contract and available at https://federalregister.gov/a/2014-23533.

15. Visitor Acknowledgment of Risks (VAR): The holder is not permitted to require clients to sign a waiver of liability statement or form, insurance disclaimer, and/or indemnification agreement waiving the client’s right to hold the CUA holder responsible for accidents or injury occurring on NPS property. The holder is permitted to request or require a client to sign a form or statement acknowledging risk and/or indicating that certain prerequisite skills may be needed to participate in the commercial activity. The holder must provide the park with the current copy of all forms and/or statements used for this purpose and obtain written approval by the park. A sample Acknowledgment of Risk form may be obtained by

Page ii of iii

https://federalregister.gov/a/2014-23533

NPS Form 10-550 (Rev. 11/2016) OMB Control No. 1024-0268National Park Service Expiration Date: 11/15/2019

contacting the CUA office at 808-329-6881 x 1330 or by going to the park CUA webpage at https://www.nps.gov/kaho/planyourvisit/permits.htm for Kaloko-Honokōhau NHP and https://www.nps.gov/PUHO/planyourvisit/permits.htm for Pu‘uhonua o Hōnaunau NHP.

16. Intellectual Property of the National Park Service: Except with the written authorization of the Director of the National Park Service, the Holder shall not assert any legal claim that the Holder or any related entity holds a trademark, tradename, service mark or other ownership interest in the words "National Park Services", the initials "NPS", or official name of any unit or part thereof, including but not limited to any facility, logo, distinctive natural, archaeological, cultural, or historic site, within the National Park System, or any colorable likeness thereof, or the likeness of a National Park Service official uniform, badge, logo, or insignia.

17. Nondiscrimination: The holder must comply with Applicable Laws relating to nondiscrimination in providing visitor services to the public and with all equal employment opportunity provisions of Title VII of the Civil Rights Act, as amended.

IMPORTANT: Before completing this application, please refer to the Application Instructions to verify that the service you are proposing is an approved commercial service. If the service you wish to provide is not listed on the table of approved commercial visitor services, contact us at the number above.Some parks have additional requirements for businesses that offer services to visitors relating to the safety and welfare of the visitors and protection of the resources. These requirements may include applicable operating licenses, certificates showing proof of training, operating plans, emergency response plans, group size limitations, etc.

1. Service for which you are applying: [attach diagram, attach additional pages, if necessary, include locations within the park, frequency, estimated number of participants (per trip and annually), number of vehicles, support equipment (trailers, generators, etc.)]

2. Will you be providing this service in more than one park? Yes No If “Yes”, list all parks and services provided.

3. Applicant’s Legal Business Name: [Include any additional names (DBA) under which you will operate.]

4. Authorized Agents: (Name and title of owner, and any onsite person authorized to manage the operation or service.)

5. Mailing AddressesPRIMARY CONTACT INFORMATION (Dates to contact you at this address, if seasonal. )

Address:

City, State, Zip:

Email: Website:

Day Phone: Evening Phone: Fax:

ALTERNATE CONTACT INFORMATION (Dates to contact you at this address, if seasonal. )

If same as “Primary Contact Information, check here and go to question 6.

Address:

City, State, Zip:

Email:

Website:

Day Phone: Evening Phone: Fax:

6. What is your Business Type? (Please check one below)

Sole Proprietor

Partnership (Print the names of each partner. If there are more than two partners, please attach a complete list of their names.)

Name:

Name:

Corporation: (State: Entity Number: )

Non-Profit (Please attach a copy of your IRS Ruling or Determination Letter)

7. State Business License Number: Expiration Date:

8. Employer Identification Number (EIN):

Page iii of v

https://www.nps.gov/PUHO/planyourvisit/permits.htm

https://www.nps.gov/kaho/planyourvisit/permits.htm


9. Liability and Vehicle Insurance:Provide proof of insurance. The CUA operator must maintain General Liability insurance naming the United States of America as additional insured. Minimum coverage amount is $500,000 per occurrence. Some activities will require increased coverage; see Park-Specific CUA Insurance Requirements (“Attachment B”). Auto Liability insurance is also required at the minimum coverage amounts described below.

COMMERCIAL GENERAL LIABILITY INSURANCESingle Purpose Activities (includes day and overnight hiking, photography and art classes, bicycling, and group camping) $500,000

Commercial Vehicle Insurance – Passenger Transport(bodily injury and property damage) Minimum per Occurrence Liability Limits*

Up to 6 passengers $1,000,0007 – 15 passengers $1,500,00016 – 25 passengers $3,000,00026+ passengers $5,000,000

* Indicated minimum per occurrence liability limit or minimum State liability requirement in State of operation, whichever is greater.

10. Will your business operate vehicles (car, truck, van, bus, taxicab, vessel, aircraft, etc.) within NPS boundaries? Yes No

If “Yes,” please give a description of each vehicle. Use additional paper, if necessary. All vehicles are required to be registered and the operators are required to have the proper licenses to operate them commercially, as required by law or regulation.

Make/Model of Vehicle License Number Year Max # Passenger Capacity Own/Rent

Make of Aircraft Tail Number Max # Passenger Capacity Own/Rent

Make/Model of VesselRegistration Number or USCG Documentation Length Max # Passenger Capacity Own/Rent

11. Employee Licenses and Certifications:Parks typically require proof of applicable licenses, registrations and certificates of training, such as; valid driver’s or pilot’s license, fishing license, vessel registration, dive certification, CPR certification, or others. Provide copies of licenses and certifications required by “Attachment A”.

12. NPS Employment:Are you, your spouse, or minor children employed within the National Park Service?

Yes No If “Yes”, please provide information below:

Employee Name: Title:

Park and Office Where Employed:

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13. Violations: To your knowledge, have you, your company, or any current or proposed employees been convicted or fined for violations of State, Federal, or local law within the last 5 years? Are you, your company, or any current or proposed employees now under investigation for any violations of State, Federal, or local law or regulation? See instructions.

Yes No If “Yes”, please provide the following information. Attach additional pages, if necessary.

Date of violation or incident under investigation:

Name of business or person(s) charged:

Please identify the law or regulation violated or under investigation:

Please identify the State, municipality, or Federal agency that initiated the charges:

Additional Detail (optional):

(Results) Action Taken by Court:

14. Fee: Please include the Application/Administrative Fee as outlined above.

15. Signature: False, fictitious or fraudulent statements of representations made in this application may be grounds for denial or revocation of the Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). All information provided will be considered in reviewing this application. Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and accurate to the best of my knowledge.

Signature Date

Printed Name Title

NOTICES

Privacy Act Statement

Authority: The authority to collect information on the attached form is derived from 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the National Park Service Commercial Services program allowing commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Providing your information is voluntary, however, failure to provide the requested information may impede the processing of your commercial use authorization application.

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Concession Management Improvement Act of 1998 (54 USC 101911). Your response is required to obtain or retain a benefit in the form of a Commercial Use Authorization. We will use the information you submit to evaluate your ability to offer the services requested and to notify the public what services you will offer. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number. OMB has assigned control number 1024-0268 to this collection.

Estimated Burden Statement

We estimate that it will take approximately 2.5 hours to prepare an application, including time to review instructions, gather and maintain data, and complete and review the proposal. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242, Reston, VA 20192. Please do not send your completed form to this address; but rather to the address at the top of the form.

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ATTACHMENT AAuthorized Services & Required Licenses, Registrations and Training Certificates

AUTHORIZED COMMERCIAL SERVICE REQUIRED DOCUMENTATION

Guided hiking/ guided photography/ birdwatching Mandatory Park Orientation- Date to be announced

Wedding ceremonies/wedding photography/portrait photography Mandatory Park Orientation- Date to be announced

Surf lessons Mandatory Park Orientation- Date to be announcedCPR, First Aid Certified

Bus tours or taxi services Mandatory Park Orientation- Date to be announcedProof of PUC license

Bicycle tours Mandatory Park Orientation- Date to be announced

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ATTACHMENT BCUA Insurance Requirements

Commercial General Liability (CGL) Insurance

Liability insurance is required for all CUA holders under the terms of the authorization. Such insurance should be of sufficient scope to cover all potential risks and in an amount to cover claims that can reasonably be expected in the event of serious injury or death. The minimum liability insurance is $500,000 per occurrence. Liability insurance policies must name the United States of America as additional insured. The business or person that is providing the service must be the named insured (policy holder).

Automobile Liability Insurance

If a CUA holder transports passengers or uses a vehicle in the performance of the service in the park, they are required to have Automobile Liability insurance. The auto liability insurance must include coverage of “owned, leased, rented or hired” vehicles if the CUA holder rents or leases vehicles. The minimum commercial auto liability insurance for passenger transport is reflected in the following table:

Commercial Vehicle Insurance – Passenger Transport(bodily injury and property damage) Minimum per Occurrence Liability Limits*

Up to 6 passengers $1,000,0007 – 15 passengers $1,500,00016 – 25 passengers $3,000,00026+ passengers $5,000,000

* Indicated minimum per occurrence liability limit or minimum State liability requirement in State or operation, whichever is greater.

Commercial auto insurance provides:

1. Liability insurance, which includes coverage for bodily injury, property damage, uninsured motorists, and underinsured motorists;2. Physical damage insurance, which includes collision insurance; and; 3. Other coverage, which includes medical payments, towing and labor, rental reimbursement, and auto loan coverage.

Taxis that do not provide tour services are only required to have Auto Liability insurance. The Commercial General Liability covers out of vehicle activities and taxis do not provide out of vehicle activities.

Insurance Company Minimum Standards

The NPS has established the following minimum insurance company requirements. All insurance companies must meet the following minimum standards. These standards apply to foreign insurance companies as well as domestic companies.

1. All insurers for all coverages must be rated no lower than A- by the most recent edition of Best’s Key Rating Guide (Property-Casualty edition), or similar insurance rating companies (Moody’s, Standard and Poor’s, or Fitch), unless otherwise authorized by the Service.

2. All insurers for all coverages must have Best’s Financial Size Category of at least VII according to the most recent edition of Best’s Key Rating Guide (Property-Casualty edition), or similar insurance rating companies (Moody’s, Standard and Poor’s, or Fitch), unless otherwise authorized by the Service

3. The insurance ratings must be submitted with the CUA Application. The rating companies do not issue certificates. We require the insurance broker to note this rating in the Certificate. If the rating does not appear on the certificate, the insurance broker must provide it in another document.

Proof of Insurance Submission

Applicants must submit proof of insurance with the CUA Application. The proof of insurance must:

Be written in English with monetary amounts reflected in USD Reflect that insurance coverage is effective at time of CUA Application submission Name as insured the business or person that is providing the service Name the United States as additionally insured Reflect a General Commercial Liability Policy with the minimum coverage amount required in the CUA Application Reflect required additional insurances (commercial vehicle, vessel, aircraft, etc.) with the minimum coverage amount required in the CUA

Application Include insurance provider rating or provide in separate document

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A report is required for each Commercial Use Authorization (CUA) issued. These instructions correspond to the numbered questions in Form 10-660.

1. Enter the contact information for the holder and primary contact as written on the CUA.

2. Enter the service the holder is authorized to provide as it appears on the CUA.

3. Enter the number of clients who made use of the commercial services provided under this CUA. Note: If you already submit monthly reports, we only require you to add the monthly reports together.

4. Enter the average number of hours or days a customer spends in the park engaging in your service.

5. Check the box that best describes the level of importance the park plays in providing the commercial services authorized under this CUA.

6. Enter the percentage of time clients spend in the park when engaged in the commercial service authorized under this CUA.

Example: If you take clients on ten (10) mile rafting trips and eight (8) of the ten (10) miles are inside the park, then 80% of the activity takes place in the park OR If you spend four (4) hours on a hike and the last hour is hiking outside the park then you spend 75% of the activity in the park.

7. Enter total gross receipts for the holder (applicant) for the most recent business year. This is the total gross receipts the company brought in, regardless of whether or not the gross receipts are a result of the service provided under this CUA. Enter the total amount in US dollars. Gross receipts will not be made public by the Service except in accordance with law.

8. Enter the portion of gross receipts that are a result of providing the service authorized under this CUA. Enter the total amount in US dollars. Gross receipts will not be made public by the Service except in accordance with law.

Example: If the park is the exclusive destination for clients participating in the services provided, then 100% of the holder’s gross receipts are a result of visiting the park. If the services provided within the park are primary or incidental, or the visit to the park is part of a multi-destination tour, then estimate what percentage of gross receipts are directly attributable to visiting the park.

9. Provide details of any reportable injuries incurred by the holder, the employees of the holder, or clients within the park during the term of this CUA.

10. Check the box to indicate interest in applying for a CUA when this one expires.

11. Signature of business owner or authorized agent.

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COMMERCIAL USE AUTHORIZATION APPLICATION

Pu‘uhonua o Hōnaunau NHP and/or Kaloko-Honokōhau NHP and/or Po Box 129

Honaunau, HI, 96726 CUA Coordinator

Phone Number: (808) 329- 6881 ext 1330

For Calendar Year: 2017

DUE BY: Febuary 1

1. CONTACT INFORMATION:Holder Name: Contact Person (if different) Contact Person (if different) Business Name Email (business) Mailing Address Winter Summer(Street Address) Email (contact person) (City, State, Zip Code) Phone Winter Summer Fax Winter Summer

2. SERVICES PROVIDED: (As it appears on your authorization.)

VISITOR USE INFORMATION

3. VISITORS AND/OR TRIPS:Enter the number of clients serviced within the park over the past year: Enter the number of trips (if applicable) your company made to the park over the past year:

4. LENGTH OF STAY: (If applicable)Enter the average length of time your clients were in the park as a result of the service you provided (if applicable). For day trips, show the average number of hours that you spend in the park per trip. For overnight trips show the average number of nights that you spend in the park per trip from the first travel day to the last day exiting the park.

Average hours per trip: (Trips that use lodging outside of the park are considered day trips.)

Average number of nights per trip:

(If provided, use table below to report total visitor use numbers.)

(See “Attachment A”).

5. The park is:

the EXCLUSIVE destination for your clients. (This means it is the only designation being offered on the trip, not including brief stops along the way. 100% of your trip is a result of your visiting the park.)

a KEY DESTINATION or a SIGNIFICANT LOCATION. (This means it is one of several sites where your services are provided. Some percentage of your trip is a result of being in the park.)

6. What percentage of the service you provide is a result of visiting the park?

FINANCIAL INFORMATION

7. Enter the total gross receipts for your operation:

8. Enter the portion of the total gross receipts earned that resulting from visiting the park: (See Instructions)

RECORDS RETENTION. TEMPORARY. Destroy/Delete 3 years after closure. (NPS Records Schedule, Commercial Visitor Services, Page 1 of 1(Item 5D) (N1-79-08-4))


INJURY INFORMATION

9. Did any reportable injuries occur during your trips this year? Yes No

If “Yes”, please use a separate sheet of paper to report the date of the incident and a brief statement of the incident. Include a description of the activity taking place at the time of the injury, the type of injury, and the action taken to provide patient care. Please include the sex and age of the patient (omit the patient’s name). A reportable injury involves any medical incident or injury requiring medical aid beyond Basic First Aid and/or when a request for medical aid/rescue assistance is made. You do not need to send in a report if you have already done so.

RETURNING

10. Our company plans to return next year. Our company does not plan to return.

11. SIGNATURE: False, fictitious or fraudulent statements or representations made in this report may be grounds for denial or revocation of the Commercial Use Authorization and may be punishable by fine or imprisonment (U.S. Code, Title 18, Section 1001). Authorized Agents must attach proof of authorization to sign below.

By my signature, I hereby attest that all my statements and answers on this form and any attachments are true, complete, and accurate to the best of my knowledge.

Signature Date

Printed Name Title

NOTICES

Privacy Act Statement

Authority: The authority to collect information on the attached form is derived from 16 U.S.C. 5966, Commercial Use Authorizations.

Purpose: The purposes of the system are (1) to assist NPS employees in managing the National Park Service Commercial Services program allowing commercial uses within a unit of the National Park System to ensure that business activities are conducted in a manner that complies with Federal laws and regulations; (2) to monitor resources that are or may be affected by the authorized commercial uses within a unit of the National Park System; (3) to track applicants and holders of commercial use authorizations who are planning to conduct or are conducting business within units of the National Park System; and (4) to provide to the public the description and contact information for businesses that provide services in national parks.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside the National Park Service as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Providing your information is voluntary, however, failure to provide the requested information may impede the processing of your commercial use authorization application.

Paperwork Reduction Act Statement

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501), please note the following. This information collection is authorized by The Concession Management Improvement Act of 1998 (54 U.S.C. 101911). Your response is required to obtain or retain a benefit in the form of a Commercial Use Authorization. We will use the information you submit to evaluate your impact to park resources and compliance with park regulations and limitations. We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid Office of Management and Budget control number.

Estimated Burden Statement

We estimate that it will take approximately 1.25 hours to prepare a report, including time to review instructions, gather and maintain data, and complete and review the report. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 12201 Sunrise Valley Drive, MS-242 Rm. 2C114, Reston, VA 20192. Please do not submit your form to this address, but rather to the address at the top of the form.

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ATTACHMENT A

CUA ANNUAL REPORT

Guided Tours:

Month Number of Trips Number of Visitors Number of Guides1

January February March April May June July August September October November December

TOTAL: 1 The number of times the guides led trips. If there are 2 guides on each trip and 5 trips, the total number of guides is 10.

Surf Trips

Month Number of Trips Number of Visitors Number of Guides1

January February March April May June July August September October November December

TOTAL: 1 The number of times the guides led trips. If there are 2 guides on each trip and 5 trips, the total number of guides is 10.

Page 3 of 3


2018 COMMERCIAL USE AUTHORIZATION CHECKLISTKaloko-Honokōhau NHP and/or Pu‘uhonua o Hōnaunau NHP

U.S. DEPARTMENT OF THE INTERIORNational Park Service73-4786 Kanalani St #14Kailua Kona, HI 96740

PH: (808) 329-6881 FAX: (808) 329-2597

BUSINESS NAME:

Completed 2018 CUA Application

Payment ($200.00 one park/ one year, $300.00 two parks/ one year ; check payable to “National Park Service”.

Insurance Certificate (Comprehensive General Liability)

Insurance Certificate (Automobile Liability) must show VIN #

PUC License (If new)

Annual Report for 2017

Annotation on the insurance that names the U.S. Government, National Park service as additional insured

Certificate Holder Address is:

U.S. Government, National Park Service, 73-4786 Kanalani St. 14, Kailua Kona, HI 96740

Mail application packet to:

National Park Service, Commercial Services, 73-4786 Kanalani St. 14, Kailua Kona, HI 96740

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